Healthcare Provider Details

I. General information

NPI: 1417378092
Provider Name (Legal Business Name): UTTERBACK RX INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2013
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S MAIN ST SUITE 2
CONRAD MT
59425-2532
US

IV. Provider business mailing address

600 S MAIN ST SUITE 2
CONRAD MT
59425-2532
US

V. Phone/Fax

Practice location:
  • Phone: 406-278-3267
  • Fax: 406-278-3851
Mailing address:
  • Phone: 406-278-3267
  • Fax: 406-278-3851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number20440
License Number StateMT

VIII. Authorized Official

Name: BRANDON UTTERBACK
Title or Position: OWNER
Credential:
Phone: 406-278-3267